Exposure therapy for specific phobias in children and adolescents

C H A P T E R

8 Exposure therapy for specific phobias in children and adolescents Lynn Mobach, Ella Oar and Jennifer L. Hudson Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia

Specific fears, such as a fear of the dark, a fear of certain animals, or a fear of heights, are very common in children and adolescents (Ollendick, King, & Frary, 1989). In most cases, these childhood fears are a short-lived, normal part of development and do not cause any clinically significant interference or distress. However, for 10 22% of children and adolescents (Kessler, Chiu, Demler, & Walters, 2005; Muris & Merckelbach, 2000; Muris, Merckelbach, Mayer, & Prins, 2000; Ollendick, Hagopian, & King, 1997), these fears are severe and chronic and cause significant distress in daily life, warranting a diagnosis of specific phobia. Specific phobia is one of the most prevalent anxiety disorders in childhood and adolescence and, unlike popular thought, can be debilitating and can interfere with children’s and adolescent’s lives on a daily basis (Deacon, Lickel, & Abramowitz, 2008; Ollendick, Davis, & Sirbu, 2009). To be diagnosed with a specific phobia, a child must present with a marked fear of a specific object or situation, which is not in accordance with the actual danger posed by that object or situation [Diagnostic and Statistical Manual of Mental Disorders Fifth edition (DSM-5), American Psychiatric Association (APA), 2013]. Exposure to the object or situation must trigger an immediate fear or anxiety response and the person must go out of their way to avoid the object or situation, or the person

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can only endure exposure with extreme distress. The specific fear must significantly interfere with daily functioning in the context of the home, school, and with friends and must have been present for at least 6 months. Additionally, DSM-5 specifies that the specific fear must not be better explained by any other mental health condition. For example, in the case of a specific phobia for contracting an illness/disease; considerations for differential diagnoses entail ruling out obsessive compulsive disorder as a better explanation of the fear. The DSM-5 further classifies specific phobia into five main types, which include (1) the animal type, including all animals and insects, (2) the natural environment type (NET), which include the dark, thunderstorms and lightning, water, and heights (3) the blood-injection injury (BII) type, which includes seeing blood, getting injections, and undergoing blood tests, (4) the situational type, which includes elevators, lifts, and other enclosed spaces, but also flying, and (5) the other type, which includes doctors or dentists, choking, vomiting, costumed characters, and contracting an illness or disease (APA, 2013).

Case example Lily, a young girl who has just turned 10 years old, presents with a specific fear of dogs. Lily’s parents are desperate for her to get rid of her fear of dogs, as it is getting harder and harder for the parents to get Lily out of the house. They have just moved into a neighborhood close to Lily’s school, where many of Lily’s schoolmates also live. However, there is a big problem with the new neighborhood: there are many families with dogs in the neighborhood and in their own street. Lily has never been really fond of dogs and was never one to run up to pat a dog. However, ever since they have moved to their new house, Lily has become extremely frightened of the possibility that she will encounter a dog on the streets when she goes out of the house and therefore often refuses to go to school, and/or over to a friend’s house. She will only go by car and her parents have to pick her up from all her activities. When Lily encounters a dog on the street she is completely seized by fear and starts to run. This response has placed Lily in danger on a number of occasions. For example, there was a time that she ran up on the streets in front of a moving car when a dog came out of one of the houses on their street.

Treatment plan I: assessment A thorough assessment is integral to the development of an effective treatment plan for a client with specific phobia and assists the clinician

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in achieving multiple goals. First, as specific fears are quite common in normally developing children, it is paramount to do a thorough assessment of the specific fear to be able to distinguish developmentally appropriate specific fears from debilitating, persisting specific fears (i.e., is the specific fear present at a clinical level). Second, a thorough assessment enables the clinician to look at differential diagnoses and possible other comorbid psychiatric disorders (e.g., other specific phobias, other anxiety or mood disorders) which should be taken into account when developing the treatment plan. Third, the clinician can determine the severity of the specific phobia. Fourth, the clinician can determine the nature and level of the fear, the catastrophic beliefs, and the level of behavioral avoidance. Lastly, a thorough assessment before starting the treatment provides the clinician with a benchmark to evaluate treatment outcomes (Oar, Farrell, & Ollendick, in press; Silverman & Ollendick, 2005). Evidence-based assessment for specific phobias in children and adolescents should be both multi-method and multi-informant (Ollendick & Davis, 2012; Silverman & Ollendick, 2005). Multi-method refers to using multiple methods, such as a clinical interview, additional questionnaires, and a behavioral assessment. Multi-informant refers to including information from multiple informants, such as both the parents and the child, and in some cases, it might be relevant to obtain information from the child’s teacher (Ollendick & Hersen, 1993). With both children and adolescents, it is important to gain the perspective of both the parents and the child; it is not unusual for younger children to give a low interference rating, while the parents give a high interference rating. For adolescents, it is not unusual for it to be the other way around (Rapee et al., in press). Below, we offer recommendations as to how to conduct an evidence-based assessment for specific phobias.

Clinical interview and additional questionnaires The first step in an evidence-based assessment for specific phobia is not unlike any other psychiatric disorder assessment; the clinician starts with a semi-structured clinical/diagnostic interview. The gold standard diagnostic interview for assessing anxiety in youth is the Anxiety Disorders Interview Schedule for the DSM-IV (there is no version yet for the DSM-V; ADIS-IV-C/P; Silverman & Albano, 1996). The ADIS-IV has a child and parent version and assesses all major anxiety disorders, mood disorders, and provides screeners and additional modules for both externalizing disorders (e.g., attention-deficit/hyperactivity disorder) and other disorders (e.g., pervasive developmental disorders). Although all modules of the ADIS-IV-C/P can be administered

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independently, it is recommended that the full interview is completed with the child and the parent(s) separately (Ollendick & Davis, 2012) to thoroughly assess for the presence of any other comorbid disorders. Additionally, it is recommended that the clinician starts the clinical interview with an assessment of the broader family (psychiatric) history, family composition and background, and developmental history (e.g., milestones) to embed the interview within the wider context of the child and their family and to establish rapport with the child and parents (Ollendick & Davis, 2012; Ollendick & Shirk, 2011). A broad assessment is needed to be able to assess whether there are other comorbid anxiety, mood, or other disorders (e.g., externalizing or pervasive developmental disorders) present. Interestingly, the presence of other anxiety disorders has not been found to have a negative impact on specific phobia treatment outcome and it was even found that specific phobia treatment has been related to less symptoms in comorbid ¨ st, anxiety disorders (Mobach, Gould, & Hudson, in press; Ollendick, O Reuterskio¨ld, & Costa, 2010; Ryan, Strege, Oar, & Ollendick, 2017). However, other comorbid disorders may have an impact on treatment outcomes. For example, comorbid ADHD symptoms have been found to predict poorer treatment outcome for specific phobia (Halldorsdottir & Ollendick, 2016). It is highly recommended that the clinician asks detailed questions to gain a better understanding of the nature and severity of the child’s fear. Gathering precise information about the child’s fear is crucial for tailoring their treatment plan. Examples of questions for Lily could be: “What kind of dogs are you scared of, big/small, a specific color, a specific breed?” “Are there any times that you are able to be around dogs and not feel scared, e.g., on a leash or if they were in a different room in the house?” “What parts of a dog are you most afraid of (e.g., teeth, paws, head)?” “Are there any particular behaviors dogs have that make you scared, e.g., jumping, running, barking?” Furthermore, as exposure treatment is primarily focused on challenging the child’s catastrophic beliefs about the phobic object or situation the clinician should complete a functional analysis of the phobia to assess these catastrophic beliefs (Davis, 2006), maintaining factors, and factors that have evoked the fear. The clinician can ask a variety of questions to elicit the child’s core catastrophic belief (e.g., “Imagine that a dog is in the room with us now, what do you fear will happen?”). In the case of Lily, she might answer that she is afraid that the dog will jump up against her and bite her in the face. The clinician should then obtain ratings (on a scale from 0 to 10) of several aspects of the catastrophic belief that give an indication of the child’s threat expectancies: (1) a probability rating, indicating how likely it is that the belief would occur, (2) a severity rating, indicating how bad it would be if the catastrophic belief were to come true, and (3) a self-efficacy rating, indicating the

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¨ st & belief in the ability to cope with the fear (Ollendick et al., 2009; O Ollendick, 2001). With regards to precipitating factors, Lily does not report a negative incident with a dog in her past. The key maintaining factors are Lily’s avoidance and her parents’ accommodation of her fear. For example, her parents have stopped visiting family members and they drive her around by car. Alongside clinical interviews with the child and the parent(s), administration of questionnaires can give the clinician a more comprehensive picture of the child’s (subclinical) symptomology. Questionnaires can be administered to both the child and the parents and should be focused on the specific phobia, and other anxiety-related and psychopathological symptoms. We recommend administering a measure focused on the specific phobia (and other anxiety disorders), as well as a broad measure, focused on general psychopathological symptoms. With regards to specific phobia measures, there are some questionnaires available that focus on a particular specific phobia subtype (Silverman & Ollendick, 2008), such as the Spider Anxiety and Disgust Screening for Children (Klein, van Niekerk, Baartmans, Rinck, & Becker, 2017). Alternatively, another reliable and valid instrument that measures a range of fears is the Fear Survey Schedule for Children Revised (FSSC-R; Ollendick, 1983). The FSSC-R is a self-report questionnaire for youth (aged 7 16) on which they can rate 80 specific objects and situations on how fearful that would make them. The FSSC-R has both a child and a parent version. With regards to other general psychopathological symptoms, the clinician can choose from general anxiety measures and measures spanning the broader psychopathology spectrum. In the case of the former, the Spence Children’s Anxiety Scale (Spence, 1998), or revised Child Anxiety and Depression Scale (RCADS; Chorpita, Yim, Moffitt, Umemoto, & Francis, 2000) are widely used, reliable, and valid instruments. In contrast to the SCAS, the RCADS also assesses depression symptoms. When the clinician wants to assess broader psychopathological symptoms, the Child Behavior Checklist (CBCL; Achenbach, 2001) or the Behavior Assessment System for Children (BASC; Reynolds, Kamphaus, & Vannest, 2011) are both good options. The CBCL and the BASC both focus on internalizing and externalizing symptoms and both scales have a parent and teacher version.

Behavioral assessment A behavioral assessment is a crucial component of the assessment phase for specific phobias. The Behavioral Assessment Task (BAT; Ollendick & Davis, 2012) is a standardized, controlled (exposure-based)

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behavioral assessment, which involves the child/adolescent approaching their phobic object or situation. For example, Lily might be asked to enter a room and pat a dog for 30 seconds. Children are advised that the task is voluntary and that they can stop at any time. The degree to which the child is able to engage with their feared object/situation provides an objective measure of avoidance. The BAT is scored based on the percentage of steps [e.g., open the door (Step 1), stand 2 m from the dog (Step 5), and pat the dog on the head for 30 seconds (Step 10)] the child is able to complete during the task (Ollendick & Davis, 2012). For example, Lily asked to stop the task after opening the door to the BAT room and seeing the dog (Step 1), hence she would score 10% for her BAT. The BAT gives the clinician objective information about the child’s complete phobic response (e.g., cognition, physiological, and behavioral), which cannot be obtained via clinical interviews and questionnaires. This information is crucial to treatment planning as it provides a foundation from which to build a graduated exposure hierarchy. The child’s behavior during the BAT gives an indication of the starting point for exposure and their ability to manage their anxiety when confronted with their feared object/situation. The clinician can also gain insight into of the amount of fear experienced by the child by asking them to rate their subjective units of distress (SUDs), for example on a scale from 0 to 10. The BAT can also give the clinician an indication of any safety behaviors that the child might use. Safety behaviors are behaviors that will alleviate the anxiety and distress caused by the phobic object/ situation in the short term. Examples of common safety behaviors for a child with a specific phobia are the presence of a parent or in Lily’s case, wearing a winter coat. Importantly, some safety behaviors may not express behaviorally (the child may distract him/herself by thinking about something else) and have to be prompted by the clinician: “Are you doing anything to make yourself less anxious/nervous now?.” Children may not always be aware of these safety behaviors and it may be a good idea to ask the parents about possible safety behaviors during the assessment phase. The clinician can choose to do the BAT on the same day as the initial assessment or on a separate visit. The latter is recommended, especially when the phobic stimulus is not readily available. The clinician can plan the BAT as a separate visit before treatment starts as part of the treatment planning. Just as with the actual exposure session(s), the clinician has to think about how they are going to arrange the phobic stimulus. When the phobic stimulus/situation is not readily available, the clinician has to be creative. For example, in the case of a phobia for thunderstorms or lightning, the clinician can choose to let the child enter a dark room with a video and sounds of thunderstorms or lightning.

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Integration assessment results Once the clinician has completed a comprehensive assessment, the results have to be integrated. Unfortunately, discrepant findings between the multiple informants are all too common. However, these discrepancies can also be very informative and can help the clinician in setting up the treatment plan. For example, when the parents do not report any safety behaviors, but the clinician did identify them during the assessment phase, he or she can integrate this in the treatment plan by planning a short psychoeducation session explaining what safety behaviors are. The clinician will have to use his or her clinical judgment to develop an effective treatment plan. See Table 8.1 for a summary of Lily’s assessment phase.

Treatment plan II: how to do exposure Treatment options For young people suffering from specific phobias, cognitive behavioral treatments (CBT) have the strongest evidence base (Davis & Ollendick, 2005; Ollendick, King, & Chorpita, 2006). These interventions typically include exposure, cognitive restructuring, and psychoeducation with exposure believed to be the most important treatment component (Ale, McCarthy, Rothschild, & Whiteside, 2015). CBT has been successfully delivered to phobic youth using a variety of formats, including spaced weekly sessions (e.g., Cool Kids Program; Rapee et al., in press), intensively (i.e., One Session Treatment; OST; Davis, ¨ st, 2009), and via the internet (Vigerland et al., 2013). To Ollendick, & O date, the majority of controlled trials for phobic youth have evaluated the effectiveness of an intensive CBT approach known as a “One Session Treatment.” This treatment involves a single massed exposure session (maximum 3 hours; Ollendick & Davis, 2012). OST utilizes a range of CBT techniques such as gradual exposure, psychoeducation, ¨ st, cognitive restructuring, and modeling (Ollendick & Davis, 2012; O 1989) and is now considered a well-established treatment for adults, as well as children and adolescents (Davis, May, & Whiting, 2011; Davis & Ollendick, 2005). The main difference with traditional exposure treatment is that during OST the child works through their entire fear hierarchy during one prolonged exposure session. Currently, no studies have directly examined the relative efficacy of spaced weekly CBT in comparison to OST for phobic youth. In contrast to CBT, the evidence for pharmacotherapy agents as either stand-alone treatment or in combination

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TABLE 8.1 Summary of Lily’s assessment phase. Part assessment

Instrument

Outcome

Clinical interview

ADIS-IVC/P

Primary diagnosis: Specific Phobia Animal Subtype (dogs). Child severity rating: 4. Parent severity rating: 6. Clinician severity rating: 5 Additional information: fear is triggered when confronted with most breeds, small and bigger dogs, but more so with bigger dogs, on and off leash, all colors. Active dogs, particularly those that jump, evoke a lot of fear.

Questionnaires

FSSC-R

FSSC-R score Lily: 136

CBCL

FSSC-R score parent: 145 CBCL-score Lily: internalizing (10), externalizing (4) CBCL score parent: internalizing (14), externalizing (7). With the exception of the parent-score for internalizing behavior, all Lily’s scores were in the normal range.

Safety behaviors

Clinician

Lily could not verbalize any safety behaviors, but her parents told the clinician she will hide behind her parents and started wearing a thick winter coat, even when it is warm outside. The parents believe Lily does this in case a dog may bite her.

Functional assessment

Clinician

Catastrophic belief: “If I approach a dog, it will jump up to my face and bite me” Probability rating: 10 Severity rating: 10 Self-efficacy rating: 1

Behavioral assessment

BAT

Percentage of steps completed: 10%; Lily was only able to open the door of the BAT room which had a dog inside in the far corner on a lead (Step 1) SUDs: 7/8

ADIS-IV, Anxiety Disorders Interview Schedule for the DSM-IV; CBCL, Child Behavior Checklist; BAT, Behavioral Assessment Task; SUD, subjective units of distress.

with psychological treatment for phobic youth is limited (Fairbanks et al., 1997; Leonte, Puliafico, Na, & Rynn, 2018). While exposure-based treatments are considered to be the most efficacious for children and adolescents with specific phobias, there remain many misconceptions about exposure which affect clinicians’ use of the technique (Prochaska & Norcross, 1999). For example, practicing clinicians often think that exposure is harmful for the patient and that it will

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increase distress. The latter is true with regard to the start of exposure treatment, when patients usually experience an increase in fear, but the fear will fade after treatment as a result of changing the catastrophic belief (Foa, Zoellner, Feeny, Hembree, & Alverez-Conrad, 2002). However, there are no indications that exposure poses harm to the patient and generally, patients tend to have a positive view on exposure (Deacon & Abramowitz, 2005; McGuire, Wu, Choy, & Piacentini, 2018; Olatunji, Deacon, & Abramowitz, 2009; Richard & Gloster, 2007). Exposure treatment involves prolonged and repeated confrontation with the feared object or situation in a systematic and controlled manner while preventing avoidance (both behavioral and cognitive). Although there usually is a decrease in fear and distress during the course of an exposure session, this is not the goal of exposure treatment, but rather a desirable side effect (Craske & Mystkowksi, 2006; Foa et al., 2002). The goal of exposure treatment is to tackle the catastrophic belief the child or adolescent has by staying in the feared situation for the amount of time that allows the child or adolescent to (1) learn that the catastrophic belief will not happen and (2) to learn that they can tolerate the fear. There are multiple types of exposure: exposure in vivo, imaginal exposure, and interoceptive exposure. An example of exposure in vivo is “live” exposure to the phobic stimulus, such as arranging a dog for Lily. Although exposure in vivo is the most widely used and preferred exposure type, interoceptive exposure can be effective with certain phobias. Integrating elements of interoceptive exposure can be useful when the phobia involves a fear for physical sensations, such as a BII phobia or a specific phobia for heights. For example, interoceptive exposure for BII phobia could be focusing on the disgust the child feels in their body. Exposure in vivo produces greater improvements than imaginal exposure and is typically not a preferred exposure type for younger children as it involves abstract thinking: children may be limited by their developmental capacities and have greater difficulty with imaginal exposures (Davis & Ollendick, 2005). However, imaginal exposure can be a good alternative when the feared object or situation is very impractical to arrange, such as sharks or planes. Another alternative with such situations may be exposure through virtual reality. Some children may have difficulty articulating their belief about the feared situation and this makes developing exposures more challenging for the clinician. In this case, the parents can be a useful guide to assist in determining what the child is fearful of within the situation (see the section on Involving the family). The clinician can also make suggestions to the child, based on what they ascertained from the assessment. For example, “I am wondering whether when you see a dog you worry that it might bite you?” This suggestive questioning may assist in understanding the child’s belief. However, it may sometimes be

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necessary to develop the exposures with limited understanding of the belief. This will mean some greater “trial and error” as the clinician works to ascertain in a gradual way, which aspects of the feared situation create increased arousal for the child.

Exposure treatment: how does it work? The mechanism of exposure treatment for fear and anxiety is thought to be extinction-based (inhibitory) learning (Craske et al., 2008; McGuire & Storch, in press). A fear of a specific object or situation is thought to have its origins in three learning pathways: classical conditioning, vicarious conditioning, and the transmission of negative information (Rachman, 1977). A specific phobia originating from a direct negative experience with an object or situation is thought to be the result of classical conditioning (King, Gullone, & Ollendick, 1998; McGuire et al., 2016). For example, Lily might have had an experience in which a dog bit her. Classical conditioning theory states that because of this experience, Lily has developed an association between the conditioned object (the dog) and the unconditioned stimulus (biting). Because many people with a specific phobia do not report such a prior negative experience, or even prior contact with the object or situation, other learning experiences might play a role (King, ClowesHollins, & Ollendick, 1997; Muris, van Zwol, Huijding, & Mayer, 2010; Ollendick & Muris, 2015). A specific phobia may alternatively originate in the modeling of behavior toward the feared object or situation. For example, Lily may have a friend or parent that has exhibited a fear of dogs. Alternatively, a specific phobia may develop after (repeatedly) receiving negative information about an object or situation. In Lily’s case, her dog phobia might originate from learning about a friend who has been bitten by a dog. When a child continuously experiences the object or situation in absence of the feared outcome (catastrophic belief), as in exposure sessions, the link between the object and the catastrophic belief will fade and extinction takes place (Pavlov, 1927; Urcelay, 2012). However, it must be noted that research indicates that the original response (fear and avoidance) will not entirely fade. Instead, it is thought that exposure creates a new learned response (no/acceptable fear and approach) which will be practiced as the new dominant response; hence, the term “inhibitory learning” (Bouton, Westbrook, Corcoran, & Maren, 2006; Hermans, Craske, Mineka, & Lovibond, 2006).

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Features of a good step ladder A fear hierarchy is the crucial component of a well-thought out and successful exposure treatment protocol. For children and adolescents, a fear hierarchy is often referred to as a step ladder. The step ladder is composed of the steps a child or adolescent is going to take during the exposure session(s) to achieve the goal the clinician and child have decided upon. The step ladder is gradual, meaning that the steps are increasing in difficulty to be able to finally achieve the ultimate goal. A first step to take when creating a step ladder together with the child and parents is to identify a goal that the child wants to achieve by the end of the exposure treatment. By identifying a goal, the clinician and the child have something to work toward and it will help with evaluating the treatment. When Lily was asked about her goal during the treatment planning phase, Lily and her parents agreed that her goal would be to give a big dog a cuddle. The clinician or the family may think that this is too much and that, for example, petting a dog would also be enough of an end goal. However, exposure treatment is thought to be most successful when there is a certain degree of overlearning and when the exposure task is challenging enough that it ¨ st, 1989; Peris gives the child a sense of mastery after its completion (O et al., 2017). Overlearning can be operationalized as taking steps toward the feared object or situation that a person would normally not engage in, in their natural environment. In Lily’s case, this might involve her giving the dog a cuddle, while in her natural environment she might function well enough if she can just walk past a dog. Another example would be a spider crawling over a client’s entire body in the case of a spider phobia. The idea behind overlearning is that this will lead to the greatest violation of the child’s catastrophic ¨ st, 1989). Of course, the end goal should be formulated belief (O together with the child/adolescent and the parents, and all should be on board to work toward this goal. After choosing a goal, the second step into creating a step ladder for the child would be to review the information the clinician has taken away from the assessment phase. Information from the functional and behavioral assessment can now be transformed into a step ladder.1 Together with the child or adolescent, the clinician can start to think about the steps that are necessary to obtain this goal. To identify situations in which the child would encounter the feared object or situation and in which they would be fearful, they can use a worry scale to give all 1 In clinical practice, the functional assessment phase usually already involves creating steps of the step ladder. For clarity purposes, we have separated these two phases in this chapter.

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the identified feared situations a worry/fear rating on a scale from 0 (very relaxed) to 10 (extremely worried/scared). This can help the clinician and child with making a step ladder for the child and decide which steps can be taken first and which ones should be saved until the very end (for an example, see the Cool Kids manual; Rapee et al., 2019). When creating the step ladder, the clinician should keep in mind the characteristics of the feared object or situation that were particularly fear evoking for the child. For example, during the functional assessment, Lily mentioned that she was especially fearful of large, active dogs. The clinician should make sure that this information is incorporated into the step ladder. Importantly, when working with children, the clinician should take the developmental level into account: young children may find it especially hard to think abstractly about how the different steps might make them feel (Holmbeck, Greenley, & Franks, 2004). The clinician can work around the cognitive limitations by concretizing and visualizing the step ladder as much as possible. For example, the clinician may use separate cards on which the child and clinician write down the different situations they identify, after which the child can put them into an order from the least difficult to most difficult (Chorpita, 2007; Davis et al., 2009). See Fig. 8.1 for an example of Lily’s step ladder. When developing exposure steps, clinicians should remember that useful steps are (1) specific, which means that each step is formulated in such a way that it exactly states what the child needs to do, (2) repeatable, which means that the step must entail an activity that the child can repeat multiple times in a week when they are practicing at home, and (3) in the child’s control, which means that the step should entail an activity that the child can do by themselves or with the help of a parent. Also, the steps should be gradual and increasing in difficulty. We recommend determining at least 8 12 steps in the step ladder. After the steps have been chosen, the next step is to choose rewards for reaching the ultimate goal and also for completing the smaller steps. Save a larger reward, such as a big outing with the family or a friend, for achieving the ultimate goal. The child can choose smaller rewards, such as choosing dinner, extra screen time, or special treats or desserts, for achieving each of the steps (Rapee et al., in press).

Fighting fear by facing fear Once the step ladder is created, the next task is to start exposure sessions. Developed at the Centre for Emotional Health, the Cool Kids Program (a program that teaches anxiety management skills to children and adolescentshould be adolescents meeting criteria for a primary anxiety disorder) makes use of a Fighting Fear by Facing Fear form

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FIGURE 8.1 Example of a step ladder for Lily.

(Lyneham, Wignall, & Rapee, in press). This form will help the clinician to both plan and track the steps of the step ladder. The clinician and child fill out the plan at the beginning of each week (depending on the frequency of the sessions) and plan ahead which steps will be carried

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out, when they will be carried out, which coping strategies the child might use (e.g., thinking of realistic thoughts that have been formulated during detective thinking/cognitive restructuring), and what the worry rating is for those steps at the point of filling out the form. During the session, the clinician should repeatedly ask for worry and fear ratings to evaluate whether the child has stayed in the situation for long enough to move on (i.e., to experience a fear drop and learned that the catastrophic belief will not come true). Once the session has been completed, the Fighting Fear by Facing Fear form can be filled out together with the child to evaluate how the session went. The clinician and child can fill out the worry rating during and after the exposure session. Also, they can fill out what the child has learned from the session and the clinician should ask for ratings of the threat expectancies (i.e., probability, severity, self-efficacy). Finally, the child should receive the reward that he/she has picked out. Importantly, in between sessions, the child or adolescent should continue to practice with the steps. The clinician and the child can come up with plans for the homework together and they should discuss how much the child should practice. Depending on the phobic stimulus/situation, the homework can take place naturally (e.g., dogs on the street in the case of a dog phobia) and/or planned (e.g., visiting a dentist in the case of a dentist phobia). In both cases, the clinician should plan the steps to be practiced during the homework carefully with the child and the family to ensure enough practice takes place. As a guideline, the child should practice the planned steps enough to experience a fear drop in the situation and to be able to formulate a learning experience. The clinician and child should evaluate the homework at the beginning of the following session. See Table 8.2 for an example of a Fighting Fear by Facing Fear form completed with Lily for two of the steps in her step ladder.

Tips and recommendations when doing exposure After creating the step ladder, the actual exposure session(s) may seem simple; just follow the steps. However, there are a lot of things to think about when preparing for an exposure session and important things to think about during an exposure session. We have outlined some tips and recommendations below which we adapted from the Cool Kids program (Rapee et al., in press). 1. Be prepared. The clinician should prepare for the session by making sure the feared object or situation is ready and available for the exposure. For example, in Lily’s case, the clinician should make sure a dog is available for Lily’s practice. The clinician should pick a dog

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Tips and recommendations when doing exposure

TABLE 8.2

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Example for fighting fear by facing fear for Lily.

Planning

Review

What step will I do? When will I do it?

What strategies will I use?

Worry ratings

What did I learn?

What reward did I receive?

Step 1. Look at videos of dogs—Monday

Think of realistic thoughts from detective thinking.

Today: 5

The dogs look friendly

Go for ice cream with dad.

The dog does not pay attention to me and does not come up to me.

Going to the movie theater with mum

During: 3 After: 1

Step 4. Look at a dog through an open window— Tuesday

Think of realistic thoughts from detective thinking. Not wearing my safety jacket.

Today: 7 During: 5 After: 2

that is calm to begin with, then end with a dog that moves around more, but will not bite. If a clinician is uncomfortable or unfamiliar with the feared object or situation, the clinician has to practice confidently handling the object of situation him/herself before starting the exposure session. Furthermore, it is important that the clinician uses calm body language and facial expressions, as even subtle anxious modeling can lead to avoidance of the feared object or situation in the child. If the clinician feels they are not up for it, they should outsource the treatment to a colleague. 2. Be flexible. Situations may evoke more fear than initially thought by the child. Historically, the child has avoided the situation, so the actual situation may be harder or easier than the child originally thought. Another step may need to be added before moving on to the next step if it turns out to be too hard for the child. The clinician should adapt the step ladder where needed. 3. Expect the unexpected. When conducting exposure, the clinician should be prepared for the unexpected with exposure tasks not always going to plan. Exposure for specific phobias often involves the use of animals and is frequently conducted outside of the office in natural surroundings. Hence, there are a number of aspects of the session which are not under the clinician’s control. For example, a dog may suddenly jump up or bark, a spider may crawl into a sweater, or something may fall over in the dark. It is important that the clinician uses these opportunities to model calm behavior and to empathize with the child’s experience. Moreover, the clinician should take these opportunities to reinterpret the event and use it as a learning experience. For example, if a dog jumps on Lily during her exposure

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4.

5.

6.

7.

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session, the clinician could use this opportunity to ask Lily if her feared outcome had come true (e.g., “Let us calm down for a bit and look at what happened. The dog jumped up to you, but did your worst fear come true? You were scared for a moment, but you could handle the fear. Very good!”). Balance the difficulty of the steps. The clinician should make sure that the steps in the step ladder are neither too easy nor too difficult. The child should feel as though each step is somewhat challenging, but not too challenging so that the child can experience a sense of mastery when they have completed a step. Safety behaviors. Although the goal of the exposure for the child is being in the feared situation without engaging in safety behaviors, it is sometimes a good idea to let the child practice the first steps with the safety behavior (Salkovskis, Clark, Hackman, Wells, & Gelder, 1999). The child may be too scared to start with the first steps and by practicing the first steps with safety behaviors, the clinician can motivate the child to be in the feared situation. For example, a child with a specific phobia of the dark may first enter a dark situation with a flashlight. The clinician and child should work toward fading out the safety behaviors over sessions, so that the child learns that the fear fades and the catastrophic belief does not come true despite not using safety behaviors. Vary contexts. As mentioned before, extinction learning is highly context-dependent and it is therefore paramount that the clinician practices exposure in a variety of situations and with varying features of the stimulus (Wolitzky-Taylor, Viar-Paxton, & Olatunji, 2012). For example, Lily should practice with different dog breeds, different sized dogs, and in different situations. Another example, with regards to a specific phobia for elevators, the clinician should practice in different buildings, varying in the number of floors and how old the elevator is. Let the fear drop. The clinician should make sure that the child stays in the situation long enough for the fear to drop and so the child has learned something new (e.g., the dog does not pay attention to me and does not come up to me when I look through the window). Ideally, the fear drops substantially, but as a minimum, the fear should drop at least two points but often this varies depending on the way the child uses the scale. The important thing to remember is that the child should experience a reduction in fear. However, there are instances in which the child stays very fearful and fear ratings do not drop. In this case, the clinician should manage expectations for the child and repeat that although the fear does not drop now, this does not mean that there is no progress and reiterate the child’s achievement (“Although you are still feeling very scared, you are still in

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the situation and your worse fear has not come true, good job!”). The most important focus should always be on discrediting the catastrophic beliefs. 8. Repetition. The key to any successful exposure session is repetition. Each step should be repeated until the child or adolescent feels bored with the step or the anxiety has significantly dropped. The clinician can check this by repeatedly asking for fear/worry ratings. 9. Realistic expectations. Prepare the child or adolescent that there will be good and bad days. The child should know that it is normal that sometimes they might experience more fear in the same situation they could easily face on previous days. Remind the child that it is important to keep on trying.

Maintaining improvement After successful exposure treatment, the child or adolescent has learned that the catastrophic belief is not true, or a lot less believable than they had first thought when starting treatment. As a consequence, the fear has usually subsided and the child or adolescent is able to come into contact with the object and/or be in the situation, without extreme fear and avoidance. Furthermore, the child has learned important skills to handle fear that may arise in the situation or close to the feared object. However, as with all skills, it is important to keep on practicing to be able to maintain the skillset and the results. As mentioned before, extinction learning is highly context-dependent and the original response (fear and avoidance) is still intact, therefore, exposure results are not immune to relapse (Urcelay, 2012). To be able to maintain the desired, new response to the object or situation, it is crucial to generalize the skills and the new response to various contexts by letting the child or adolescent practice at home and in different situations. Even after treatment has ended, for traditional exposure treatment, within the context of CBT or for OST, it is important that the clinician strongly encourages the child/adolescent and their family to continue to expose themselves to the feared object or situation to maintain treatment results. The clinician should make concrete plans with the child during the treatment to make sure that the child has a maintenance plan. It is also advisable that the clinician follows up with the family to ensure they are practicing at home. The same recommendations apply for this maintenance plan as was true for the homework assignments: the steps should be specific, repeatable and under the child’s control. This could include specific daily/weekly tasks. For Lily, this could entail visiting the neighbor’s dog or playing with friends who own a dog (Table 8.3).

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TABLE 8.3 Summary of the steps toward an evidence-based treatment plan. Step

Phase

Component

Step 1

Assessment

Clinical/diagnostic interview (including functional assessment)

Step 2.

Assessment

Additional questionnaires

Step 3.

Assessment

Behavioral assessment

Step 4.

Treatment

Create a fear hierarchy

Step 5.

Treatment

Facing fear by facing fear: exposure session(s) 1 homework

Step 6.

Maintenance

Practicing

Involving the family Involving the parents in the design of stepladders can be important for a successful exposure. This is particularly critical for younger children to help guide appropriate timing and spacing of each step. For the most part, parents will be able to use their extensive knowledge of the child’s anxiety and coping skills to assist the clinician and child to calibrate each step. In some families, this may be more difficult. For instance, some parents may worry that the child will not be able to complete a step and underestimate their child’s ability to cope. In this case, the parent may suggest a step that is too easy for the child and this results in a missed opportunity for tackling a more difficult step. Other parents may want to push their child through the steps too quickly and hence end up increasing the likelihood of failure. As we mentioned earlier, the child should feel as though each step is somewhat challenging but not too challenging so that the child can experience a sense of mastery. It is also important that there is sufficient time within the course of treatment to tackle the most difficult exposures, so if progress is too slow, then it will mean there is less time to tackle the difficult steps. In this instance, the clinician may want to encourage the family to consider a more difficult step than the parent suggests. Parents are less important for guiding the process of developing and executing stepladders for adolescents. Clinicians can use this as an opportunity to encourage more independence in the young person as they develop their own step ladders and take responsibility for managing their own anxiety. However, parents will still be required to ensure that the exposure is feasible within the family’s weekly schedule and can help the young person, if needed, to set up the exposure, making sure the feared stimuli are available and transport is available. For children of all ages, parents may be important for identifying barriers to successful completion of

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the exposure tasks and may be useful to assist the child and the clinician in problem-solving ways to increase the likelihood the exposure tasks will be completed. Ultimately, the child/adolescent needs to be able to execute each step independently from their parents. However, it may be necessary for parents to help support the child in the first instance. For example, a child who is scared of the dark may require the parents to be present when they complete the first few steps (e.g., holding the child’s hand, or standing within close proximity) until the child is ready to complete the step on their own. Parent presence may make the steps easier for the child to complete and increase the likelihood that the step is completed. As mentioned previously, parents can also be important in determining and delivering rewards for the child. In a collaborative process, the parents and child can decide on appropriate rewards for each step.

Tips and tricks One of the most frequent barriers to the successful completion of stepladders is parent anxiety. When a parent has high anxiety, this may not only prevent the appropriate calibration of the steps in the planning phase, but it can also serve as a barrier to executing the steps. Parents with high anxiety may prevent the child from starting the step or may remove the child from the situation too early because of an unrealistic fear that the situation is dangerous. The parent may also communicate unhelpful messages to the child that the situation is scary or that they don’t believe the child is able to complete the step. This could present as a fearful or uncertain facial expression or it could present as more overt statements like “I hope it doesn’t hurt you.” Parents with high anxiety may also provide the child with too much reassurance, like “It’s okay. You will be okay. Nothing bad will happen.” In a recent study in our Center, we showed that when parents were asked to encourage their child to approach an unknown animal, parents of anxious children gave significantly more statements of reassurance than parents of nonanxious children (Anagnos et al., in preparation). These parents were also less likely to encourage the child to approach the animal than parents of children without an anxiety disorder. Another study examining parents’ behavior during children’s medical procedures suggests that reassurance not only communicates to the child that the parent is worried about the situation, but actually serves to increase the child’s distress (McMurtry, Chambers, McGrath, & Asp, 2010). During exposures in which an anxious parent is present, it can beneficial to coach parents about the most appropriate response. For

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example, parents can be encouraged to communicate to the child their confidence in the child’s ability to complete the task. For many parents, this may mean providing a single statement about the child’s ability to complete the task at the beginning of the task and then sitting back (and not rushing in to reduce the child’s distress) and trusting that the child will complete the task on their own. The Cool Kids program focuses on teaching parents the strategies to manage their child’s fears, but these strategies may also be beneficial for parents in managing their own anxiety. The clinician may encourage the parent to develop his/her own gradual exposure hierarchy. This may be particularly useful for parents who experience the same fear as the child and are unable to provide support for their child to complete the exposure tasks. We might encourage the parent to complete a similar stepladder before the child is asked to start their hierarchy, so the parent can be supportive for the child’s task. Having said that, the program is not sufficient to treat parental anxiety disorders and if the parent’s anxiety is impacting on their ability to appropriately support their child during exposure, then parents should be encouraged to seek additional treatment. Another option might be to involve only the nonanxious parent in the treatment program.

Challenging issues While carrying out exposure therapy for specific phobias may appear straightforward, there are a number of challenges that a clinician may need to overcome in order to achieve a successful treatment outcome. Common challenges or pitfalls include children’s lack of motivation, access to phobic stimuli, and difficulties maintaining treatment gains. Phobic children may present with limited motivation to overcome their fear (Oar, Farrell, & Ollendick, 2015). For example, in the case of injection phobia, children may not have the capacity to comprehend the long-term health-related benefits of receiving an injection and thus have low motivation to face their fear. As previously discussed, the use of tangible rewards is critical to reinforce non-anxious behaviors and increase child motivation. Exposure tasks should also be as enjoyable and engaging as possible (e.g., hide and seek with glow sticks for a dark phobic child). With these children, it is important that prior to commencing exposures, the therapist spends sufficient time building rapport with the child and ensuring that the child has a good understanding of the rationale for treatment. A significant challenge for clinicians working with phobic children and adolescents is the sourcing of appropriate stimuli for treatment. For example, when working with an animal phobic child, the clinician must

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seek out a number of different animals to be involved in sessions (e.g., small dogs, large dogs, calm and active dogs, and particular dog breeds). Considerable time also needs to be spent planning where exposure sessions will take place. In relation to animal phobias, if treatment is occurring within the clinic, the animals (e.g., dogs, spiders, snakes, bees, birds) will need to be stored prior to and following the session. They may also require food and water. Additionally, the clinician may need to seek permission from building managers to have animals onsite. Alternatively, if exposure is taking place offsite at a home, park or other public space, the clinician will need to consider who will be present when conducting exposure tasks as well as the child’s safety. For instance, when working with a child who has a lift phobia, the clinician should consider the busiest time of day in the building and/or how to respond if a member of the public approaches the child during an exposure task—particularly if the child has become distressed. It is important to contemplate and mitigate any potential risks when working with children. For instance, if the child has a water phobia, and the clinician is taking them to the beach, they will need to ensure that if the child is able to go into the water that they are swimming in a safe area (e.g., paddling between the lifeguard flags). At times the clinician may need assistance and have to work alongside other members of the public or health professionals to deliver treatment. An example would be when treating an injection phobic child, the clinician may need to work with doctors, dentists, or nurses. Scheduling appointments with the clinician, family, and other busy health professionals is often difficult and is further complicated by the cost associated with having two health professionals involved. Importantly, members of the public and other health professionals often require some form of training/preparation themselves before they are involved in an exposure task. For example, exposure assistants should be taught to avoid reinforcing phobic behaviors (e.g., comforting the child and encouraging them to avoid if they become distressed during the exposure task) and to be aware of verbal threat messages they may give (e.g., “Yes I heard about a pitbull biting a child recently on the news but my dog wouldn’t do that.”). The difficulties faced by clinicians in sourcing suitable stimuli for exposure are also experienced by families. Hence, setting up and carryout home exposure practices requires considerable time and active planning. In our experience, this appears to be one of the greatest barriers to continued exposure practice and consequently maintaining treatment gains in phobic youth. Prior to exposures, the clinician should meet with parents to brainstorm and problem solve as to how they will access stimuli on a regular basis (e.g., contact a local dog obedience school; speak with an airline about going on a standby list for domestic flights).

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Moreover, to enhance compliance with exposure practice, it is recommended that the clinician schedule regular telephone calls or face-toface sessions with the family to address barriers (e.g., lack of time and access to stimuli) to practicing. We have highlighted some of the challenges in working with phobic young people and briefly provided suggestions for how to overcome ¨ st (2012) these. It is recommended that readers see Reuterskiold and O for a comprehensive review of different phobia subtypes and how to tackle specific challenges related to working with these presentations. Despite these challenges, working with phobic children is highly rewarding and interesting. Exposure therapy for these youth is highly effective. However, for it to be successful clinicians need to be organized and creatively design exposure tasks that maximally violate children’s phobic beliefs.

Conclusion Specific phobias are one of the most common anxiety disorders affecting children and adolescents. While children typically experience a range of fears over the course of their development, for a significant proportion of young people these fears persist and cause significant distress and impairment in functioning. Comprehensive phobia assessments include clinical interviews, questionnaires, and behavioral approach tasks with both children and their parents. A thorough assessment provides the foundation for the development of a successful and individualized treatment plan. Exposure-based treatments, delivered either intensively or via spaced, weekly sessions, have been found to be efficacious for phobic youth. When conducting exposure with phobic children and adolescents, it is important that the clinician is prepared and is flexible in their delivery of exposure varying the pace of the session in response to the child’s needs. To ensure treatment gains are maintained, it is important that a maintenance plan is established and that the parents are involved.

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Prochaska, J., & Norcross, J. (1999). Systems of psychotherapy: A transtheoretical analysis (4th ed). Pacific Grove, CA: Brooks/Cole. Rachman, S. (1977). The conditioning theory of fear acquisition: A critical examination. Behavior Research and Therapy, 15, 375 387. Rapee, R.M., Lyneham, H.J., Schniering, C.A., Wuthrich, V., Abbott, M.A., Hudson, J.L., & Wignall, A. (in press). The Cool Kids child and adolescent anxiety program therapist manual. Sydney: Centre for Emotional Health, Macquarie University. ¨ st, L. G. (2012). Real world applications of one-session treatment. Reuterskiold, L., & O ¨ st (Eds.), Intensive one-session treatment of In T. E. Davis, III, T. H. Ollendick, & L. G. O specific phobias (pp. 127 141). New York: Springer. Reynolds, C. R., Kamphaus, R. W., & Vannest, K. J. (2011). Behavior assessment system for children (BASC). In Encyclopedia of clinical neuropsychology (pp. 366 371). New York: Springer. Available from doi:10.1007/978-0-387-79948-3_1524. Richard, D. C. S., & Gloster, A. T. (2007). Exposure therapy has a public relations problem: A dearth of litigation amid a wealth of concern. In D. C. S. Richard, & D. Lauterbach (Eds.), Comprehensive handbook of the exposure therapies (pp. 409 425). New York: Academic Press. Ryan, S. M., Strege, M. V., Oar, E. L., & Ollendick, T. H. (2017). One session treatment for specific phobias in children: Comorbid anxiety disorders and treatment outcome. Journal of Behavior Therapy and Experimental Psychiatry, 54, 128 134. Available from https://doi.org/10.1016/j.jbtep.2016.07.011. Salkovskis, P. M., Clark, D. M., Hackman, A., Wells, A., & Gelder, M. G. (1999). An experimental investigation of the role of safety behaviours in the maintenance of panic disorder with agoraphobia. Behaviour Research and Therapy, 37, 559 574. Available from https://doi.org/10.1016/S0005-7967(98)00153-3. Silverman, W. K., & Albano, A. M. (1996). The anxiety disorders interview schedule for DSMIV-child and parent versions. London: Oxford University Press. Silverman, W. K., & Ollendick, T. H. (2005). Evidence-based assessment of anxiety and its disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34(3), 380 411. Available from https://doi.org/10.1207/s15374424jccp3403_2. Silverman, W.K., & Ollendick, T.H. (2008). Child and adolescent anxiety disorders. In: A guide to assessments that work, pp. 181 206. doi: 10.1093/med:psych/ 9780195310641.003.0009. Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36(5), 545 566. Available from https://doi.org/10.1016/s0005-7967(98) 00034-5. Urcelay, G. P. (2012). Exposure techniques: The role of extinction learning. Exposure Therapy (pp. 35 63). New York, NY: Springer. ¨ st, L. G., Lindefors, N., . . . Serlachius, Vigerland, S., Thulin, U., Ljo´tsson, B., Svirsky, L., O E. (2013). Internet-delivered CBT for children with specific phobia: A pilot study. Cognitive Behaviour Therapy, 42(4), 303 314. Available from https://doi.org/10.1080/ 16506073.2013.844201. Wolitzky-Taylor, K. B., Viar-Paxton, M. A., & Olatunji, B. O. (2012). Ethical issues when considering exposure, . Intensive one-session treatment of specific phobias (208, p. 195). New York, NY:: Springer.

Further Reading Albano, A. A., & Kendall, P. C. (2002). Cognitive behavioural therapy for children and adolescents with anxiety disorders: Clinical research advances. International Review of Psychiatry, 14(2), 129 134. Available from https://doi.org/10.1080/09540260220132644.

II. Implementing exposure by diagnosis

Further Reading

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¨ st, L. G. (1997). Rapid treatment of specific phobias. In G. C. L. Davey (Ed.), Phobias: A O handbook of theory, research, and treatment (pp. 63 80). Chichester: John Wiley. ¨ st, L. G., & Ollendick, T. H. (2017). Brief, intensive and concentrated cognitive behavioral O treatments for anxiety disorders in children: A systematic review and meta-analysis. Behaviour Research and Therapy. Available from https://doi.org/10.1016/j. brat.2017.07.008. ¨ st, L. G., Svensson, L., Hellstrom, K., & Lindwall, R. (2001). One-session treatment of speO cific phobias in youths: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 69(5), 814 824. Waters, A. M., Farrell, L. J., Zimmer-Gembeck, M. J., Milliner, E. L., Tiralongo, E., Donovan, C. L., . . . Ollendick, T. H. (2014). Augmenting one session treatment of children’s specific phobias with attention training towards positive stimuli. Behaviour Research and Therapy, 62, 107 119. Zlomke, K., & Davis, T. E., III (2008). One-session treatment of specific phobias: A detailed description and review of treatment efficacy. Behavior Therapy, 39(3), 207 223. Available from https://doi.org/10.1016/j.beth.2007.07.003.

II. Implementing exposure by diagnosis